Novo Nordisk: An Ecosystem Approach to Preventing Diabetes

Introduction

Novo Nordisk is a global healthcare company that employs 43,200 people and is headquartered in Bagsværd, Denmark. The company has been involved in diabetes care for more than ninety-five years and is also a provider of services and advice for the treatment for haemophilia, growth disorders, obesity, and a number of other serious chronic diseases. It has strategic production sites in five countries, and affiliates or offices in eighty countries. The firm produces around 50 per cent of the world’s insulin and also makes several drugs under a variety of brand names and became a corporation after a merger in 1989. It is a member of the European Federation of Pharmaceutical Industries and Associations (EFPIA). In October 2018, Novo Nordisk was ranked the fifth most reputable company for corporate responsibility by the business magazine, Forbes, the only pharmaceutical company within the top thirty.

Type 1 Diabetes

Type 1 diabetes is a lifelong disease. People with type 1 diabetes are dependent on insulin treatment for survival. Their condition is caused by the body’s inability to produce insulin which results in glucose remaining in the blood rather than being absorbed by cells. It is therefore vital that people living with type 1 diabetes receive daily insulin treatment.

Type 2 Diabetes

Type 2 diabetes is a chronic disease. It occurs when your body cannot make enough insulin—the hormone that controls the amount of glucose in your blood—and cannot use the insulin it does make effectively. This is called insulin resistance, and it develops over months, or even years. Diagnosed early, type 2 diabetes can be controlled with diet and exercise. If diet and exercise alone are not enough to control your glucose levels, you may also need to take medication. It’s important to be screened for diabetes and to recognize the symptoms early. You are more likely to develop type 2 diabetes if you are middle aged or older, if you are overweight, and if you have a family history. Warning signs include: extreme thirst, excessive urination, tiredness and fatigue, blurry vision, and weight loss. There are different stages of type 2 diabetes. If you have pre-diabetes, your blood sugar levels can be controlled with lifestyle changes, including a healthier balanced diet, and regular physical activity. If the condition progresses, your doctor may recommend medication to help keep your blood sugar controlled.

Novo Nordisk capabilities cover the entire pharmaceutical value chain, from idea exploration and early research, upscaling, clinical testing, and regulatory submission to ultimately bringing new innovative medicines and devices to patients. Throughout the journey from idea to medicine, the aim is to create the perfect conditions for scientists’ inventions to become reality.

Ecosystem Pain Points

Around 212 million people have undiagnosed type 2 diabetes worldwide according to International Diabetes Federation estimates in 2017. Many have developed complications by the time they are diagnosed, including damage to their feet, eyes, kidneys, and heart. Four out of five people with diabetes live in low- and middle-income countries, where many lack access to diabetes care, either because it is not available or not affordable. Cities are widely considered the frontline in the fight against diabetes and two-thirds of all people with diabetes live in urban areas.

While many developing countries are increasing the proportion of their wealth spent on health care, across the world urban populations are expanding so quickly that it is difficult for health infrastructure to keep up. Unplanned urban growth is also a major driver of poverty. Currently, 900 million people worldwide live in urban slums. The United Nations estimates that by 2030, roughly 60 per cent of city inhabitants will be under the age of 18. Many city hospitals also become overcrowded because patients recognize that’s where to find the best doctors, research, and technology. This means primary care is neglected, which can lead to unregulated, unsafe, and ineffective private services. In some African cities, public primary healthcare has almost disappeared, according to the World Health Organization (WHO). Cities can also influence how people live, travel and eat; factors which all have an impact on health.

Business Strategy

Novo Nordisk has a core purpose of driving change to defeat diabetes and other chronic diseases. Its philosophy has been to ‘discover, develop, and manufacture better biological medicines and make them accessible to people with diabetes throughout the world’. However, the firm recognizes that it takes more than medicine for people to live a full and healthy life with diabetes. Today, 425 million people—around 9 per cent of the world’s adult population—live with diabetes, the majority with type 2 diabetes, a number that has doubled since 2000 and is expected to reach 629 million by 2045.

In 2014, the company launched Cities Changing Diabetes in response to what it called the ‘unsustainable global rise of type 2 diabetes’. This platform created a public–private partnership that was focused on the idea of bringing different stakeholders and expertise together to find common solutions and address a complex public health issue: the rise of diabetes in urban areas. The programme coined this term ‘urban diabetes’.

The initiative came at a time when the spotlight was focused on the effects of diabetes. The previous year, Mexico City had become the first in the world to levy a tax on sugary drinks, which was considered a factor in the country having among the world’s highest obesity and diabetes rates.

In partnering with patients, policymakers, health-care professionals, and non-governmental organizations, Novo Nordisk hoped to address diabetes risk factors in urban areas and ensure that people with diabetes were diagnosed earlier and that they would have access to adequate care to be able to live their lives with as few limitations as possible. There were three global partners, Steno Diabetes Center Copenhagen, University College London, and Novo Nordisk, working together with more than a hundred local partners across the partner cities.

Its aims included putting urban diabetes at the top of the global health-care agenda. From the group’s experience, it has been shown that the greatest impact on potentially devasting diseases can be when health-care systems are mobilized to see it as an urgent priority. The group has estimated that obesity must be reduced by 25 per cent globally in order to hold the rise of diabetes prevalence at 10 per cent globally.

Putting urban diabetes on the agenda of those shaping cities for the future is also important: urban planning has a key role to play in delivering health improvements. The group also set itself a challenge of investigating the challenge, the root causes, and risk factors underlying the burden of diabetes in cities, while driving action to halt the rising prevalence of diabetes and improve health outcomes. Five cities—Copenhagen, Houston, Mexico City, Shanghai, and Tianjin— joined the programme, which was later expanded to include fourteen more—Johannesburg, Rome, Vancouver, Xiamen, Hangzhou, Beijing, Jakarta, Buenos Aires, Milan, Merida, Madrid, Leicester, Koriyama, and Beirut.

Since 2014, the partnership has followed a systematic approach of building evidence by mapping the challenge in partner cities, defining and piloting actions on the ground, and sharing findings and outcomes. It refers to this as the map–share–act framework:

Map: The research conducted within the programme contributes to a holistic and multi-disciplinary approach to tackling diabetes in cities. It supports the understanding of the challenges and enables action to be taken while sharing the learnings through peer-reviewed publications, policy papers, research tools, as well as knowledge sharing within research networks.

Share: The programme aims to break down silos in order to lead to significant gains in efficiency and effectiveness. City government (18 per cent), the research sector (22 per cent), and local NGOs such as community organizations and patient organizations (26 per cent) are the main sectors involved with the programme at city level.

Act: The role of the programme is to promote, facilitate and accelerate major initiatives in diabetes prevention and management. According to Novo Nordisk’s 2014-2016 Impact review, the programme initiated 18 projects, across six cities, with the majority concerning community involvement in health (30 per cent), health-promoting policy (38 per cent), and health system strengthening (27 per cent).

An Urban Diabetes Toolbox has also been created to enable cities around the world to create an action plan for tackling the conditions; and partners across nineteen cities are collaborating to generate new knowledge and insights.

The key tools include a Diabetes Vulnerability Assessment, a research tool for identifying city-level factors that make certain groups of people vulnerable; the Diabetes Projection Model, which illustrates how reducing the prevalence of obesity would reduce the burden of diabetes; an Urban Diabetes Risk Assessment tool, which identifies the shared priorities and attitudes towards health and diabetes in a group of participants; and the Quantitative Research Tool, a framework that illustrates where gaps need to be closed to ensure that everyone with diabetes is diagnosed, treated, and has a better outcome.

In late 2015, Novo Nordisk formed a research-based partnership with C40, the Cities Climate Leadership Group which connects more than eighty-five of the world’s greatest cities.

Prognosis

Almost three years of research was conducted between 2014 and 2016 into the risk factors for type 2 diabetes, specifically the socio-cultural factors; an internal partnership review was carried out by an impact assessment team at Novo Nordisk, supported by University College London, and Steno Diabetes Center Copenhagen. It included thirty-six partner interviews and externally conducted trend analysis of coverage compared with comparative cities Monterrey, Oslo, Hangzhou, Beijing, Dallas, and Milan. The assessment considered the programme’s benefits and impacts, value drivers, challenges, and ideas for the future.

The review found that by the end of 2016, a total of eighteen projects or activities had been initiated collectively across Mexico City, Copenhagen, Houston, Tianjin, Shanghai, and Rome. Although several initiatives apply to more than one action arena, the majority of the actions initiated concern community involvement in health (38 per cent), health-promoting policy (26 per cent), and health-system strengthening (31 per cent). However, according to the impact review urban planning is the action arena with the fewest activities by end of 2016 (5 per cent).

Initiatives have included:

• In Mexico City, the partnership worked to address barriers through the establishment of a specialized diabetes centre with the capacity to treat 8,000 patients annually in Iztapalapa, one of the poorest suburbs of Mexico City.

• In Copenhagen, a peer-to-peer programme helped ‘vulnerable’ men manage their health, engage in the local community, and potentially rejoin the labour market. There are future plans for the programme to be included in the city’s health promotion and prevention activities.

• A presentation of the Tianjin Cities Changing Diabetes programme at a stakeholder dialogue hosted by the World Economic Forum at the request of the WHO’s Global ordination Mechanism on NCDs.

Meanwhile Cities Changing Diabetes partners wrote an open letter as a wake-up call for urban health, which was posted in The New York Times ahead of the Habitat III, the UN Conference on housing and sustainable urban development.

Looking towards the future, the review found that when speaking about how benefits and impacts have been achieved, the partners listed a range of topics pertaining to how the partnership is managed, with flexibility and openness a key driver of success.

Some interviewees advocated a more standardized and systematic approach to the Cities Changing Diabetes partner selection and partnership management, however most agreed there was no ‘one size fits all’ approach. Interpersonal connections were cited as very important, even when there is nothing new to report, to continuously nurture and strengthen partner relationships and progress partnership activities. The most frequently mentioned challenge was limited resources.

Several interviewees called for more action on the ground based on existing and emerging research results including evaluating ongoing interventions, and developing and measuring the impact of research-based interventions to identify the most efficient and effective ways of improving diabetes prevention and management. Several of the partners interviewed proposed that a more targeted intervention approach may be a way to maximize the impact.

Examples included targeting programme interventions towards specific target groups, such as young people, or around particular challenges, such as primary prevention, screening, or improved control of people with diagnosed diabetes.

Impact measurement and evaluation were considered necessary by most stakeholders interviewed; however, there is no unified answer regarding how this could be done and at what level. While measuring the impact of targeted interventions at city level is widely considered fairly straightforward, understanding the impact of a portfolio of interventions and, not least, impact across cities and countries is considered to be a greater challenge.

Some argue that measuring changes in health outcomes across cities is the only way that the programme can keep its focus on driving change in the long term, requiring the programme to take a uniform and systematic approach to impact measurement.

One key theme for the future is the enhanced collaboration and partnership expansion. Although some partners were concerned that a focus on onboarding new cities will come at the expense of keeping the attention on continued research and implementing already initiated local actions, the majority supported expansion to more cities at national and international levels. Central to this was a call for increased and enhanced collaboration and sharing of best practices across cities.

Case Study Contributors

• Ben Jackson, Freud Communications

• Yassine El Ouarzazi, Mars Catalyst

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